Beware the left-sided gallbladder

A left-sided gallbladder is a rare biliary anomaly with a prevalence of 0.2%. Its identification is important because of the numerous and potentially hazardous associated biliary and vascular anomalies that may be encountered during surgery.     

Beware the malignant jellyfish

Small pleural effusions that cannot be assessed by thoracentesis prior to surgery may represent a diagnostic challenge in the patient with a resectable, non–small cell cancer of the lung. Even if the effusion is drained preoperatively and analyzed, the cytology may be falsely negative. We have found that careful inspection of pleural effusions using a single small 2-cm incision and video-assisted thorascopy may reveal a gelatinous piece of clotlike material that resembles a jellyfish. This cohesive particulate piece of material lies in the effusion. This material can be sent for frozen section (unlike cytologic exams in most hospitals), and an immediate answer can be obtained. Cytology results of the surrounding effusion that return 24 hours later confirm the frozen section findings. If malignant, this avoids thoracotomy and pulmonary resection in a patient with unsuspected T4, stage IIIB lung cancer. It also avoids closing a patient with an unsuspected effusion and having to wait 24 hours for the cytology results. We review our experience with this jellyfish-like material.     

Beware the ischiorectal abscess

INTRODUCTIONIschiorectal abscesses have been shown to form sinuses with various deep structures but continuity with the spinal canal is extremely rare.PRESENTATION OF CASEA previously healthy sixty-five year old man presented emergently with rectal pain, weight loss and recurrent severe tension headaches. He had systemic sepsis and resultant coagulapathy (INR 3.4) which precluded investigation of neurological symptoms by lumbar puncture. MRI rectum demonstrated a well circumscribed fluid collection with direct connection to the spinal canal and containing meningeal tissue. It extended inferiorly to the right ischiorectal fossa and abutted the natal cleft. A radiological diagnosis of ischiorectal abscess which had become continuous with a previously existing anterior sacral myelomeningocoele (ASM) was made. He was treated with broad spectrum antibiotics and a neurosurgical opinion was sought. He remained clinically unwell (septic and coagulopathic) until the abscess fistulated through the perianal skin, draining pus mixed with clear fluid (likely CSF) at which point he improved systemically.DISCUSSIONFew general surgeons would be faced with acute management of complicated ASM. Paucity of literature made application of evidence based medicine difficult. In fit healthy patients surgery is the mainstay of treatment as myelomengingoceles do not regress spontaneously. Conservative management is associated with up to 30% mortality (largely due to bacterial meningitis). The patient in this case was adamant that he did not consent to definitive surgical intervention.CONCLUSIONThis case highlights challenges encountered in the management of complicated ASM in a general hospital.     

Beware the Anomalous Portal Vein

Portal vein thrombosis is an unusual potential complication of liver resection. In our case it was due to ligation of the right branch of the portal vein during right hepatectomy in a patient without portal vein bifurcation. Hepatic angiography can delineate this abnormality and influence the choice of surgical management.     

Beware of the aberrant innominate artery

The anatomy of aortic great vessels is relevant in surgeries of the anterior neck, especially with a tracheostomy, thyroidectomy, or mediastinoscopy. Variations in their anatomy could lead to severe complications if not recognized. An aberrant high-riding innominate artery incidentally encountered during mediastinoscopy is presented.     

Beware the tyranny of impact factors

The application and interpretation of the impact factor of a journal is fraught with problems, some of which are explored in this editorial.